7 POND ST - BUILDING INSPECTION -
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� The Commonwealth of Massachusetts
� � REC.EIVED
� Department of Public Safery �µ$pECTIONAL SE VICE$
Massachusetts State Building Code(7S0 CMR)
Building Permit Applicarion for any Building other than a One-or TwmFamil D I' 1b
C (This Secflon For Official Use Only)
� Building Permit Number: Date Applied: Building Official:
� SECT'ION 1:LOCATION(Please indicate Block#and Lot#for locations foc which a street address is not available)
� � 1 nl�lc.� G✓(` `Sa.��� !�(�17v
-� No.and Street City/Town Zip Code Name of Buffding(if applicable)
�
^ �� SECTION 2:PROPOSED WORK � � � �
� Edition of MA State Code used��U�( If New Conshucfion check here O or check all that apply in the rivo rows below
� Existing Building Repair❑ Alteration Addirion❑ Demolifion ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineeri.n��Peer Review require ? I Yes ❑ No �
Brief escriptionofProposedWork: /�L�:�e c�� oU.�Y�a GC�1S/�JS d� ��9e /"oi?(Z✓ri�)�i/
d '1 '
r
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR�' �
� CHANGE IN USE OR OCCUPANCY
Check here if an E�dsHng Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): - Proposed Use Group(s): �✓1
SECTION 4:BUILDING FIEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) � (�� � 7�.0
Total Area(sq.k.)and Total Height(ft.) SaG�S ��O ✓ �. C7
SECTION 5:USE GROUP(Check as applicable) I�
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Factor F-1 ❑ F2❑ H: Hi Huazd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTTON 6:CONSTRUCTION T'YPE(Check as applicable)
IA � IB O IIA O IIB ❑ IIIA O IIIB 0 IV 0 VA 0 VB
SECTION 7:SITE INFORMATTON(refer to 780 CMR 111.0 for details on each item)
Water Su ply: Flood Zone Infocmation: Sewage Disposal:
Trench Permit: Debris Removal:
Public Check if outside Flood Zone� Indicate municipal�
A trenc w�ll not be Licensed Disposal ite❑
Private❑ or indentify Zone: or on site system❑ required�or french or specify:
permit is enclosed❑
� Railroad right-of- a : Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable� Is Structure within airport p roach area? Is their review mmpleted?
or Consent to Build enclosed❑ Yes O or No Yes❑ No ❑
SECTION S:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of ConstrucHon: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special StipulaHons:
M��i-e.-o "zl�
� � SECTION 9: PROPERTY OWNER AUTHORIZATION
.-Name and Address of Property Owner
� c
. ✓'�lv �}�i ��evlou S�'. x•.�� DI ?O
i�Iame(Print) No.and Street City/Town Zip
Property Owner Contact Information: r i
_ C��.J D9t'/1� ` 76'-]�S (0 d`f - - 1'�✓�'N-GI4r�. �J cto� , GO N�
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the proper owner hereby au iorizes
L�,r�r,�n�.�_ C�r������ ��' D � � ��P.w� � ��i�t'i�
Name Street Address City/Town State Zip
to act on the ro e owner's behalf,in all matters relarive to work authorized b this buildin ermit a licaflon.
SEC1'ION 10:CONSTRUCTTON CONTROL(Please fill out Appendix 2) �
If buildin is less tlian 35,000 cu.k.of enclosed s ace and/or not under Constructlon Control then check here O and ski Section 10.1
101 Re 'steied Professional Res� onsible for Construction Control
p , q� �,L� i p.�}�
M� � - �rv'i��i`Dt 1L� i�J-�q��_ V'ic�✓'Rri� 'ivtLtY��'f �C/L
Name Registrant) Te ephone No. e-mazl ad,,d1rpess ��m Registrafion Number
��P�1M.. � D)y7o -Q�(ilt�nr� . 7��.
Street Address City/Town State Zip Discipline ExpirafionDate_ ___. . ---
102 General Contractar � � � �
'bLIL�LtV1GlK C-GvtS1YVG�fM ��l)S � . ... �.
CompanyrName � , �I
`�U CAn�.ina—� ��(.4-�G� �
Name of Person Responsible fur Constructiun License No. and Type if Applicable _
�� I �,NP 11 �}_ `{��ul�d-.-�r--- � D�%�D
Strcet Addmss City/Town � , State . Zip
�-�51 Gal3 __ .
Tcle hone No. business Tcle hone No. mil e-mail address .
SECCION 11:.4VURI:FIZS_'C:� �IPEVS�1'PICIV INtiUI::ANCG AI'Fll><AVCI_�M.C.L C.152���C�116-
-�.,.-L ...... .............—rnsan ��n:u.[;.-c-lo - .. .�-s-_--_-
--—A G�ork`ers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be mmpleted and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ed Affidavit submitted with this a licaflon? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor +
and Materials) Total Construcrion Cost(from Item 6)_$ .7�L�
1.Buflding $ S�V Building Permit Fee=Total Consfruction Cost x �� (Insert here
2.Electrical $ v p U appropriate municipal factor)_$J r-5.
3.Plumbing $ �J .n
4.Mechanical (HVAC) $ Note:Minimum fee=$� G�:�contact municipality)
5.Mechanical Other) $ Enclose check payable to
6.Total Cost $ % S�V (contact municipality)and write check number here
� � ��SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalfles of perjury that all of the informaflon contained in this
application is�true and accurat� o e b�t y owledge and understanding.
�1 � \ � ,/ ' `� �-�-`�=Z�+"1�
r�•: �a ' / - �;�,,�ev� 4- !
Please print end sign name U `'�,� Title , _,Telephon�� Date
� rI L�2��rrU �/•l�'O�.- �i�^ �vj�'�v� �1 � �
Street� City/Town tate Zip
� '� � �
. Municipal Inspector to fill out this secHon upon applicallon approval: � �
Name ��� � Date ��
ij t CITY OF SAI.Ebt, �iI�1SS�CHL'SETTS
;• ��• BL'IID.I�'G DEP.�R'[1ff.r7 � . .
1?0 WASHINGTON$'IHFET,7'O F100R
'I1et.(97�7i5-9595
F.�:c(97�7�f0-9846
KIJtBERLEY DRISCOLL .
�fAYOR - 1lioeus ST.P�xnS
DIREC[O&OF Pl:BLIC PROPER'[Y/BL'QDLVG COaL�1IS5IO�iER
Workera'Compensation Insuraace Afifdavih BuilderslContractora/ElectrictanslPlumben � '
Anultcant Intormstion Plea�Print Lee161v
Vame ie�s�,:or�tr�riomt�.�md�: _1 ) 7[" Y��''lYl� l���v'1Y"U!�10 IU ��I )�
Addrcss: l�ll �Gu9p�� �'�
c�cyis�c�z�P:_l���rr�.� �e�.vl9l,G phones: ��f5-�57-�'Zi3
Are ygo�n employM.C6eek tde appropriate box: T of ro at -
r-�/ YPe P J (re9��$
I.I,J �am a cmploytt wit6�' _ 4. ❑ 1 am a generni contractor and 1 6.. ❑New comlruction
employees(full aad/or patt.tinx)• have hircd the wbsonuanars
2.Q 1 am a wle pmpriemr ar paMu: lis�ed an ehe aaached sheel.7 7. ❑Remodeling
>hip arul Mve no employees Thae sub-tontfaetaB hevo .8. Q Demolition
woAcing for me in any capaciry. woAcm'rnmp.insuranee. 9. Q Building addidon
[No workrn comp.ireurance S. ❑We nro a caiporntion and in �0.❑Elatrieal us or additions
rtquiml.] officas have ett'cixd thcir � - �
7.� I am a homeowner doing all woh �ght of ezemption per MGL I L�Plumbing repain or addiriona
myulf.[No workera'comp. c. 1 S2.§I(4).and we have no 12.0 Roof eepain
insuranm�equi'ed.)1 nnplayces.�No wolkm' I3.0 Otha
comµ inwrance requircd.J .
'AIIJ'O�Ipliplq 1�pll Chp�'��b0.{/1 mYtl.l�10 flll Wl lht SRIifY hl'�OW f�pq10Q IbCV VpkfA'Cp111pCq{yjq�pp�l�'In(VfRi1�W.
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K'wuenon tlw<M1¢k�6u bm muw aashd an slditiaN�eMwup Ne m�ee olMeabwnwcmn yW tlm4 vohen'mnp ppliry infmmuoo.
/am art employe�(haf 4 providing worken'rompenmNonlnapraace jor my emp(oyut 8¢/owG fbe po!!ry mpJob dle
informaliva '
Insuranre Company Vame• � (Yl VC'�F/'C
v����Ya��s�ir-��.���.a: 71�SU ('��l`Z�`dP' ?-13 Q- i`�-1'a '
1 7v Expiration Datc
JobSireAdAress: �_ FT)(l�U' S� JQIPM Y�A� Ciry/S�ate/Lip: (��7C) � ,
. ,�ttaes a copy a(the worken'eompeoiedou poliry declantlon paga(c6owing the poilry oumber end e:pintlon d�h}
. Failure W s�xurc covemge u rtquimd unJer Seclion 25A of MGL c.132 can Iwd ro the impoairion af criminal penalriw of a I
fine up ro S I,500.00 mNor one•yeu imprisonment ns woll ae civil pemitia in ihe fmm o(a STOP WORK ORDER end a fine
� of up ro 5250.00 a Jey against�he violaror. Be aiivised dut a cupy uf ihis atewmrn�may M:forwarded to Ihe Omce of .
Im�cs�igauoro af ihe nIA For insurance covemga nrificaliart � I
/do Gereby�erN/'y n/ na w� nahlu of prrJury that f!u injwmotlon provided ubove$nur md cosrere ��
� Si�atlurc' C •f pnte i �O /S �
vn�,��x c/7fs-Rs7-G2/?
. O��fd usv ady. Do rsot wiiro in thir areq m be�umplrtM by city or mwn oJjkraL
� City ar Tawn: Prrmif/Idceou p
Issuing,\ulhorily(�ircle one):
I.ISuarJ of Ilrallh 2.Bu{Iding Depar�men� ].Cily?owo Clerk J.Elmtrical lnspector 5.Plumbing Inepamr
6.Other
Cunlact Pcrmn: Phooe#:
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� TRAVELERSJ WORKERSCOMPENSATION
J
AND
_ EMPLOYERS LIABILITY POUCY
. , TYPE AR INFORMATION PAGE WC 00 00 O1 ( A)
POUCY NUMBER: t�tau�z- ��l
RENEWAL OF (7PJU6-4758P57-7-13)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA
�• NCCI CO CODE: 13439
INSURED: PRODUCER: -
BUCHANAN, DAVID DBA WILLIAM J LYNCH INS AGCY
BUCHANAN CONSTRUCTION PLUS 92 HIGH ST
171 LOWELL ST DANVERS MA 01923
PEABODY MA 01960 "
InsUred is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 09-1 2-1 4 to 09-t 2-15 12:01 A.M. at the insured's mailing address. �
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
`� B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
� item 3.A. The limits of our Ilability under Part Two are:
o= Bodily Injury by Accident: S t 00000 Each Accident
o_ Bodily Injury by Disease: S 50000o Policy Limit
_ Bodily Injury by Disease: $ �0000o Each Employee _ ,_,_
o= C. OTHER STaTES INSURANCE: Part Three of the policy applies to the states; if_any, listed here:
-� COVERAGE REPLACED BY ENDDRSEMENT WC 20 03 06A
�=
-= D. Tfiis policy includes these endorsements and schedules:
o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o�
= a. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
�= Plans. All required information is subject to verification and change by audit to be made ANNUALLv.
.�
DATE OFISSUE: 09-05-14 VE ST ASSIGN: MA
OFFICE: ORLANDO INDUS AFF 161
PRODUCER: WILLIAM J LYNCH INS AGCY 75YBM
ooiaai
� CI1Y OF S.�LE.�1, �L�SSACHL'SETTS
BL¢.D�G Dernn�n���r
I � • ' N• 1�O WASHL�IGTON$TREET,Y°F100R
�� `� 'ItL(97�7�5-9595
Fnx(97�7�i49846
KI�tgERI.EY DRISCOLI.
�YOR 'iltoaus ST.Pt�xxs
� DIREGTO&OFPI:BLiCP&OPEATY�B�IIDINGCO\L�RSSIO.iE&. �
Construction Debris Disposal Affidavit
(required for all demolition and renovarion work)
In accordance with the sixth edition of the State Building Code,780 CMR section 111.5
Debris,and the provisions of MGL c 40,S 54;
Building Pertnit# is issued with the condition Ihat the debris resulting tmm
this work shall be disposcd of in a properly licensed wnste disposal facility as deSned by MGL c
1 l 1,S I SOA.
The debris will be transportcd by:
�vcha�Gti �°��v��r�c4��
(name of hauler)
The debris will be disposed of in :
� � l.f�cb ' �G
ame:of facility) �
3c5c� �'a���- s�- Peab��q
. (address of facility)
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Commercia� Renovation PROJECT RICHARD W. GRIFFIN
� � NUMBER: 14-27 REGISTERED ARCHITECT
o C2 HOLDINGS LLC DATE: 1/13/15 GARDENSUITE
10 DERBY SQ SALEM, MA 01970 978-740-9979
7 Pond Street Salem, MA 01970 SCALE: 3/16�� = 1�-��� DALLRIGHTS RESERVED `
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1. "HC' DENOTES HANDICAPPED ACCESSIBLE FIXTURES PER 521 CMR. rn
2. G.C. TO PROVIDE ADEQUATE BLOCKING TO SUPPORT ALL SUPPLIED TOILET �
ROOM ACCESSORIES, AND TO COORDINATE WITH PLUMBER INSTALLATION OF FIXTURE Z o
CHAIRS AND SUPPORTS FOR WALL MOUNTED FIXTURES �
. 3. PROVIDE TILE BACKER BOARD (5/8" GP"DENS-SHIELD" OR EQUAL) BEHIND u- U a^^o
ALL TILED SURFACES V- W rn
4. PROVIDE ACCESSIBLE FIXTURES BY"TOTO" OR EQUAL. � � �
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CHAIRS AND SUPPORTS FOR WALL MOUNTED FIXTURES d
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4. PROVIDE ACCESSIBLE FIXTURES BY"TOTO"OR EQUAL. � F' W
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Commercial Renovation PROJECT RI(;HARD W. GRIFFIN
� � NUMBER: 14-27 REGISTERED ARCHITECT
� Z C2 HOLDINGS LLC DATE: 1/13/15 GARDENSUITE
� 10 DERBY SQ SALEM, MA 01970 978-740-9979
7 Pond Street Salem, MA 01970 SCALE: 3/16" = 1'-0" OO ALL RIGHTS RESERVED
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NOTE: SECOND FLOOR TOILET
I I ROOM IN SAME LOCATION �?' � � '" .� J �
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F,�,�� 3� DWG NO.
c. 9 � .
1 FIRST FLOOR PLAN ,� ' j A1
3/16" = 1'-0"
1. "HC" DENOTES HANDICAPPED ACCESSIBLE FIXTURES PER 521 CMR, rn
2. G.C. TO PROVIDE ADEQUATE BLOCKING TO SUPPORT ALL SUPPLIED TOILET rn
ROOM ACCESSORIES, AND TO COORDINATE WITH PLUMBER INSTALLATION OF FIXTURE Z o
CHAIRS AND SUPPORTS FOR WALL MOUNTED FIXTURES �
� �. �
' 3. PROVIDE TILE BACKER BOARD (5/8" GP "DENS-SHIELD"OR EQUAL) BEHIND U �
' ALL TILED SURFACES � �yJ �
• 4. PROVIDE ACCESSIBLE FIXTURES BY"TOTO"OR EQUAL. �-- �
� _ �
0
C� U� � �
� FAUCET;
aN � �
. ' o O HC ACCESSIBLE, � � �Z ¢ �
� ¢ SELECT TO FIT LAV W O � _
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3'-6" � x HC WAL�SINK 0 W Q J �
. SIDE TYP. in a TOTO:LT 307 OR OF � (� Q �
'� EQUAL DIMENSIONS � � � Q
�� � � x ¢ INSULATE HOT PIPES Z � QO
� � T 3'-4" O � � Z N o X AND COVER ALL � � m
io w i,: ¢ PP,OTRUDING �
M z tO � i� y N � OBJECTS � wQ
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HC i�_6�� HC � HC �
n Accessibility Fixture Mountinq
� 1/4" = 1'-0"
a
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EXIST.W INDOW 3��"x6'8"DOOR m
WITH CLOSER O � H Q
SHELF AT 3'-0"W ITH � � Q U
WALLBELOW � Z 0 (n
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..�f -__ _ I � 'NOTE: SECOND FLOOR TOILE E y �
����-"` � -__='� =--- _..__ � -_I . G- ROOM TO BE IDENTICAL E (V �
- _ --=-- . _- U � 0^"
4^ DWG NO.
��_8,�
TO FINISH A2
�TYP. TOILET RM. PLAN
U 1/2" = 1'-0"